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HTML

<?
$reg= $_REQUEST['reg'] ; 
$first_name = $_REQUEST['first_name'] ;
$connect_date = $_REQUEST['connect_date'] ;
$prob = $_REQUEST['prob'] ;
$hv_name = $_REQUEST['hv_name'] ;
$hv_phone = $_REQUEST['hv_phone'] ;
$consent = $_REQUEST['consent'] ;
$reg_count = $_REQUEST['reg_count'] ;


$to = '[email protected]';
$subject = 'New Homeless Connection';
$msg = "<html>
<head>
<title>New Homeless Connection</title>
</head>

<body>
<table cellspacing=\"0\" cellpadding=\"10\" border=\"1\" align=\"left\">
  <tr>
    <td align=\"left\" width=\"150px\">Registery No.:</td>
    <td align=\"left\"> $reg</td>
  </tr>
  <tr>
    <td align=\"left\">First Name:</td>
    <td align=\"left\">$first_name </td>
  </tr>
  <tr>
    <td align=\"left\">Connection Date:</td>
    <td align=\"left\"$>$connect_date</td>
  </tr>
  <tr>
    <td align=\"left\">Probability:</td>
    <td align=\"left\"$>$prob</td>
  </tr>
  <tr>
    <td align=\"left\">Volunteer Name:</td>
    <td align=\"left\"$><strong>$hv_name</strong></td>
  </tr>
  <tr>
    <td align=\"left\">Volunteer Phone:</td>
    <td align=\"left\"$><strong>$hv_phone</strong></td>
  </tr>
  <tr>
    <td align=\"left\">Consent Form:</td>
    <td align=\"left\"$>$consent</td>
  </tr>
  <tr>
    <td align=\"left\">Field Count:</td>
    <td align=\"left\"$>$reg_count</td>
  </tr>
  <tr>
    <td align=\"left\" colspan=\"2\">http://www.41q.org/admin/</td>
  </tr>
</table>
<br>
<br>
</body>
</html>
";

// Make sure to escape quotes

$headers  = 'MIME-Version: 1.0' . "\r\n";
$headers .= 'Content-type: text/html; charset=iso-8859-1' . "\r\n";
$headers .= 'From: Homeless' . "\r\n";





 
 
 
$host="localhost";
$username="XXXXXXXXXXX";
$password="XXXXXXXXXXX";
$db_name="XXXXXXXXXXXX";
$tbl_name="reg_add";
mysql_connect("$host", "$username", "$password") or die("cannot connect");
mysql_select_db("$db_name")or die("cannot select DB");

date_default_timezone_set('America/Los_Angeles');
$submit_date = date("m/d/y g:i A") ; 

$order = "INSERT INTO reg_add...